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San Joaquin CounW Environmental Health De artment Unit IV Well Permit Applica�tiion Supplemental <br /> JOB ADDRESS: L �/ . MIT SR u7-0 <br /> �fi '1 f CA— <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 3 (commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code,and my lice se is in full force and effect. <br /> License : t � 7 Ex Date: )! .3 1 i 1 <br /> Date, Q 00 ___ __ ___ Contractor: PREFC46101i -SAMIOL406 <br /> Signature: Title. CA- 70 l� A-6 <br /> Print Name: C11b1W—EQ - <br /> WORKER'S COMPENSATION ECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self insure for workers'compensation, as <br /> provided for by section.3700 of the labor Code, for th performance of the work for which this <br /> permit.is issued, <br /> r7 I have and will maintain workers' compensation insurec nce, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> A M E ILI c A eJ l T-EUZui TLn%J1f-L <br /> Carrier:Se Policy Number: :3�2.`� 1 l,�. �C P-0 <br /> t N 5u a CvM 0A1JJ <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the orkers'compensation law of California, and <br /> agree that if I should become subject to workers'corn ensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those prois ons. <br /> Exp. Date.,_(e ZUU Signature: <br /> Print Name: fl C.�2�1'41t712-1� <br /> WARNING:FAILURE TO$CCURE WORKERS'COMPENSA'nON COVERAGE IS UNLAWFUL.AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTIC N 3706 OF THE LABOR CODE. <br /> ZATION FOR OTHER THAN C-57 S GNING PERMIT APPLICATION <br /> !, (signatur ' licensgd auth razed r presentative), <br /> hereby authorize(print name) t RAEl tw .� ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page,of this application. <br /> tt?16t! <br /> u4037ca 11wr r4:UPEF3 rt APP <br />